Remote RN – Utilization Management & Appeals Reviewer (NY RN License Required)

Phaxis; United States; Remote; USD 72,000 - 77,000; Part time

Job summary

Phaxis is hiring a contract RN for a New York health plan. You will own clinical grievances and appeals from intake to final decision letter, applying medical necessity judgments used in utilization management.

This 100% remote (U.S.) contract role pays $52–$56/hr based on experience, with business hours and occasional evenings or weekends to meet regulatory deadlines.

Qualifications

• Active, unrestricted New York State RN license (compact alone does not qualify).
• 3+ years of RN experience.
• 2+ years of payer-side grievance and appeals work with hands-on case investigation.
• UM and/or case management experience; outpatient/home health/long-term care background.

Responsibilities

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, review, decision, and notification.
• Apply medical necessity criteria (InterQual/MCG) to outpatient, home health, DME and LTSS cases.
• Prepare case files for Medical Director review and write determinations.
• Prepare external reviews, including NYS Fair Hearings and CMS IRE/QIO cases.
• Meet CMS and NYS turnaround times, including expedited cases.

Skills

Registered Nurse

Grievances & Appeals

Utilization Management

Case Management

Education

Active NY RN License

Job description

You've done UM. You've worked appeals. Now find a role that uses both.

We're hiring a contract RN for a New York health plan (Medicare Advantage, Medicaid and MLTC). You'll own clinical grievances and appeals from intake to final decision letter, and you'll apply the same medical necessity judgment you built in utilization management.

100% remote (U.S.) | Contract | $52–$56/hr based on experience

Business hours, with occasional evening or weekend coverage for regulatory deadlines

What you'll do:

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and notification
• Apply medical necessity criteria (InterQual/MCG) to outpatient, home health, DME and LTSS cases
• Prepare case files for Medical Director review
• Write clear, compliant determination letters
• Prepare external reviews, including NYS Fair Hearings and CMS IRE/QIO cases
• Meet CMS and NYS turnaround times, including expedited cases

What you need:

• Active, unrestricted New York State RN license (compact alone does not qualify)
• 3+ years of RN experience
• 2+ years of payer‑side grievance and appeals work where you personally investigated cases and drafted the determination
• UM and/or case management experience
• Outpatient, home health, community‑based or long‑term care background (not inpatient only)
• Working knowledge of Medicare Part C and/or NY Medicaid/MLTC appeals rules

Nice to have: BSN/MSN, CCM or CPHQ, dual‑eligible experience